APPLICATION FORM

Competition : Chemical Product Design Competition

Institution : Institut Teknologi Kalimantan
Institution Address :
Institution Phone Number :
Team Name :
Project Name :

First Participant (Team Leader)

Full Name : Alhimni Rusydi Nurislam Sutanto
Student ID Card Number : 05151004
Gender : Male
Nationality : Indonesian
Place, Date of Birth : 07/10/1997
Phone Number : 081251500701
Email : alhimnirns@gmail.com
Year of Study/Semester :5

Second Participant
Full Name : Azwar Azhary Muhammad
Student ID Card Number : 05151007
Gender : Male
Nationality : Indonesian
Place, Date of Birth : 11/22/1997
Phone Number : 085652079926
Email : azwazhmuh@gmail.com
Year of Study/Semester :5

Third Participant
Full Name : Faisol Risal Jarkasih
Student ID Card Number : 05151013
Gender : Male
Nationality : Indonesian
Place, Date of Birth : 12/17/1996
Phone Number : 082154104892
Email : faisol.risal14@gmail.com
Year of Study/Semester :5
Fourth Participant
Full Name : Adhya Yani
Student ID Card Number : 05151003
Gender : Female
Nationality : Indonesian
Place, Date of Birth : 12/21/1997
Phone Number : 085247743170
Email : adhyayani21@gmail.com
Year of Study/Semester :5

Fifth Participant
Full Name : Mela Aurelia
Student ID Card Number : 05151023
Gender : Female
Nationality : Indonesian
Place, Date of Birth : 12/20/1997
Phone Number : 081528981259
Email : 05151023@itk.ac.id
Year of Study/Semester :5